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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600386
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:42:13 PM

Document Has Been Signed on 12/17/2024 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HARTNELL HOME CAREFACILITY NUMBER:
015600386
ADMINISTRATOR/
DIRECTOR:		PURUGANAN,VICTORIA C.FACILITY TYPE:
740
ADDRESS:2041 HARTNELL STREETTELEPHONE:
(510) 489-7290
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 3DATE:
12/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Jezrael Pascual, House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 12/17/2024 at 10:20 AM Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a Case Management visit. LPAs met with Caregivers, Paciencia, Winnie and Cesar. House Manager, Jezrael Pascual, arrived approximately, 1 hour later. Administrator, Victoria Puruganan was not available.

While LPA L. Alexander and K. Nguyen was conducting a complaint investigation(15-AS-20241213161313) on 12/17/2024. During record review LPAs observed Resident (R) R1 and R2 did not have a current annual medical assessment and Appraisal Needs and Services (ANS) within the last year. Staff stated that R1 was admitted to hospice care on 12/10/2024 and there were no updated ANS documenting change of conditions. LPAs observed that R3 who has a diagnosis of Dementia does not have an updated ANS on file.

LPAs obtained the following documents: admission agreement and hospice care admission for R1 and Physician's Report for R4.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2024 03:42 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 12/17/2024 at 02:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HARTNELL HOME CARE
FACILITY NUMBER: 015600386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2025
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidence by:
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Administrator agreed to self-certify that they read, understand and will comply with the regulation. In addition, send a copy of updated ANS for R3 to CCLD by POC due date.
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Based on record review and observation, Licensee did not comply with the section cited above by not completing an annual ANS for R3 which poses an immediate health and safety risk to the persons in care.
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Type B
01/14/2025
Section Cited
CCR87463

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87463 Reappraisals

-This requirement is not met as evidenced by
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Administrator agreed to self-certify that they read, understand and will comply with the regulation. In addition, send a copy of updated medical assessments (LIC602A) and ANS for R1 and R2 to CCLD by POC due date.
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Based on record review and observation, Licensee did not comply with the section cited above by not having an updated annual medical assessments and ANS for R1 and R2 in addition R1 was admitted to hospice care dated 12/11/24 without any ANS that documents change of condition for hospice services which poses an immediate health and safety risk and personal rights to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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